Human Factors in the Health Care Setting: A Pocket Guide for Clinical Instructors

By Advanced Life Support Group (ALSG), Mike Davis and Jacky Hanson

Human factors relates to the interaction of humans and technical systems. Human factors engineering analyzes tasks, considering the components in relation to a number of factors focusing particularly on human interactions and the interface between people working within systems. This book will help instructors teach the topic of human factors.

• Language: English
• Publisher: Wiley
• Release date: Nov 28, 2012
• ISBN: 9781118339688

Book preview

Acknowledgements

A great many people have put a lot of hard work into the production of this book and the accompanying course. The editors would like to thank all the contributors for their efforts. Many thanks to Christine Davis for her input into cognition and other chapters, and for reading and helpful observations throughout. Our thanks additionally go to Rachel Adams, Nicky Hainey and Jane Mooney of ALSG and the staff of Wiley-Blackwell for their on-going support and invaluable assistance in the production of this text.

Contact Details and Further Information

ALSG: www.alsg.org

BestBETS: www.bestbets.org

For details on ALSG courses visit the website or contact:

Advanced Life Support Group

ALSG Centre for Training and Development

29–31 Ellesmere Street

Swinton, Manchester

M27 0LA

Tel: [phone]

Fax: [phone]

Email: [e-mail]

Updates

The material within this book will be updated on a 5-yearly cycle. However, practice and advice may change in the interim period. We will post any changes on the ALSG website, so we advise that you visit the website regularly to check for updates (url: www.alsg.org – go to the Human factors page). The website will provide you with a new page to download and replace the existing page in your book.

CHAPTER 1

Introduction to Human Factors in Medicine

Learning Outcomes

By the end of this chapter you should be able to demonstrate an understanding of:

the historical background to patient safety

the concept of clinical error

the range of human factors

the structure and aims of this text

Introduction and Aims

The aim of this text is to help the reader improve safety in their own practice, in the teams in which they function and in their organisation. This will be achieved by understanding the human factors that contribute to error and exploring ways to prevent, circumvent or minimise these factors by developing awareness and skills.

At the beginning, it is important to state that almost all people in the healthcare professions come to work to do a good job to the best of their ability, not to make a mistake which leads to a clinical error. This book aims to provide healthcare workers with an understanding of the human factors behind clinical error, thus improving their ability to do a good job.

The Department of Health within the UK government have recently highlighted patient safety as a major issue. Many within healthcare will be aware that patient safety has been an issue throughout medical history.

Patient safety is defined as ‘the freedom from accidental injury due to medical care or from medical error’ (Kohn et al. 1999). Medical error, in this book, will be reworded as clinical error – meaning any error that has occurred in the clinical treatment of a patient. This could be caused by anyone involved in clinical care of that patient. Frequently, papers on errors talk about adverse events which are defined as errors from any cause; these may or may not be preventable. An error is any mistake that has occurred; they are specifically defined as clinical (technical) or human (non-technical).

Background Concepts

Historical Background of Patient Safety

There has been an awareness of clinical error since Hippocrates’ direction to ‘abstain from harm or wronging any man’. Prior to 1990, however, there was little in the way of literature on clinical error, and initiatives to improve quality of healthcare were sporadic (Vincent 2010). Early improvements to patient safety have been in discoveries of technical skills and systems, with the first examples coming from Semmelweiss (Jarvis 1994), whose published work in 1857 discovered that the introduction of hand disinfection reduced the spread of puerperal fever, and hence mortality. It is interesting that history has repeated itself with the handwashing audits of today, thus a discovery from the 19th century had to be re-emphasised to reduce the spread of hospital-acquired infections. Lister discovered the original concept of the use of antiseptics, but it took until the end of the 19th century for antiseptic techniques to be fully established.

Codman, an American surgeon in the early 1900s, was the first to categorise errors in surgery, culminating in the minimum standards used in the United States until 1952 (Sharpe & Faden 1998). In 1928, maternal morbidity and mortality was investigated in the UK, with national reports produced sporadically until 1952 when the ‘Confidential Enquiry into Maternal Deaths’ was set up, which continues today (CMACE